2.0 Analysis 2.1 Selecting an Aid to Navigation Since the unidirectional range light was not shown on the American marine chart used on the VENUS, the navigation personnel were not inclined to use that aid to navigation when planning the approach manoeuvre or to mention it to the pilot before or during the approach. The unidirectional range light projects over the middle of the turning basin and allows the entire surface of the turning basin to be used as a manoeuvring area. Unlike the unidirectional range light, the landmarks used by the pilot tend to restrict the vessel to the downstream portion of the turning basin. When these landmarks are used, the approach manoeuvre must be executed closer to the shoal along the downstream limit, which considerably increases the risk of grounding. 2.2 Approach Manoeuvre In this instance, the pilot decided to manoeuvre in the downstream portion of the turning basin because of the silt deposits in the upstream portion of the entrance to the turning basin and because a vessel was moored at berth B1. He chose this approach manoeuvre because he wanted to keep the vessel away from the potential hazards in the upstream portion of the basin. With a water level of 2 m above chart datum, the vessel had an under-keel clearance of about 1 m over the 10.6 m shoal in the upstream portion of the turning basin. Also, the vessel moored at berth B1 was not encroaching on the harbour entrance. To carry out his task, the pilot used his usual approach manoeuvre. By choosing a proven method, he avoided surprises and increased his chances of success. Given the number of vessel movements in the area and the low rate of accidents in Bcancour Harbour, the manoeuvre chosen and used by the pilot many times in the past would appear to have been the right choice, but it provided a smaller margin of error than the manoeuvre based on the use of the unidirectional range light. The vessel apparently swung to port suddenly and unexpectedly. This reaction is similar to that of a long narrow object that is moving sideways when one end strikes a fixed object. Although the after section of the ship's bottom was not damaged, this dynamic behaviour suggests that the vessel's stern struck an obstruction that was probably formed by silting. 2.3 Bottom Contact The spring run-off was conducive to silting. The silt deposits at several locations on the approaches show that Bcancour Harbour is subject to silting. In fact, silting is mentioned in a remark on the CHS marine chart for the area. The low manoeuvring speed of the VENUS in the turning basin had a slight effect on the squat. The vessel's deep draught (11.6 m) and considerable breadth (32.2 m) likely contributed to a more pronounced reduction in under-keel clearance. As a result, with an under-keel clearance of less than 0.74 m, the vessel was at risk of striking any shoal formed by silting. Since the vessel swung suddenly after contacting the bottom, the shoal found at the entrance to the turning basin after the grounding cannot be taken into account. If the vessel had contacted bottom at the entrance to the basin, the heavy spring current would not have set the vessel toward the bottom portion of the basin where she grounded but rather on the rocky downstream limit along the 7.3 m and 6.4 m soundings. The vessel, following the pilot's chosen approach at the entrance to the basin, would have avoided the 9.7 m shoal. Nonetheless, unreported silt deposits along the downstream limit of the turning basin in way of the grounding position cannot be ruled out as a contributing factor to this occurrence. The current off the harbour entrance tends to set vessels toward the downstream limit of the turning basin. Regardless of the approach manoeuvre selected to enter the harbour, if the vessel is to stem the current, the approach must include helm and engine manoeuvres with or without the assistance of tugs. Consequently, the timing of the changes in engine speeds is critical to the success of any manoeuvre. Because the vessel drifted toward the downstream limit, the pilot was unable to confirm with the navigation personnel that his orders had been carried out. When the pilot ordered the tug's engine stopped and the speed of the VENUS increased, he wanted to arrest the drift and move the vessel to the upstream portion of the basin, or at least to stem the current. The pilot did not ascertain that the slow ahead order he had given was carried out, and some time elapsed before he realized that the vessel was slowing down. To ensure the successful completion of the approach manoeuvre planned by the pilot, the master and the officer of the watch had to make sure that they clearly understood the pilot's orders. Thus, the possibility that the subsequent engine orders came too late and the vessel drifted to the downstream limit of the basin cannot be ruled out. The vessel would have struck the shoal along the edge and would have started swinging to port. Even at full ahead, the propeller thrust could not overcome the effect of the current against the starboard side. The vessel swung to port until the bottom came to rest against the shoal. 2.4 Bridge Resource Management Because there was little exchange of information and a lack of support between the navigation personnel and the pilot, a proper watch could not be maintained. As the navigation personnel did not keep an adequate radar watch, they were unable to inform the pilot of the proximity of the downstream limit of the turning basin during the approach manoeuvre. Therefore, the pilot had to perform a number of tasks by himself. For example, he had to keep a lookout as well as give helm and engine orders to the navigation personnel of the VENUS and the ROBERT H. There was no buoy or landmark in place along the downstream limit of the turning basin, which made lateral observation more difficult. Crews navigating in foreign waters are usually unfamiliar with local waterways. If the pilotage assignment is extended, as in this occurrence, conduct of the vessel can be difficult; consequently, in most cases, the navigation personnel tend to rely completely on the local pilot for the conduct of the vessel. The navigation personnel did not use parallel indexing on any of the three available radars to determine the limits of the turning basin. Nothing prevented them from determining for themselves the available manoeuvring space in the turning basin and from offering that information to assist the pilot. Since the navigation personnel were using a marine chart that did not show the unidirectional range light and since they did not discuss the approach manoeuvre with the pilot, they were not fully aware of all available aids to navigation. The LPA prescribes the circumstances in which vessels are required to have a pilot on board and the minimum number of licensed pilots that must be on board. However, when a marine accident occurs, only the contract between the LPA and the Corporation des pilotes du Saint-Laurent central inc. indicates how the situation should be assessed. Even if there are provisions for assessing marine occurrences, there are no regulations requiring the parties to dispatch a second pilot to the scene to relieve or assist the pilot already on board. Unless a conflict arises between the pilot and the navigation personnel, a pilot involved in a marine incident or accident must wait at least 12 hours to be relieved. 2.5 Knowledge of Marine Salvage Operations The information collected indicates that the effect of the current during the spring run-off was underestimated. When the vessel moved astern after being refloated, three of the tugs were unable to push against the side because they were not made fast to the vessel. The one tug that was secured to the vessel had insufficient bollard pull. Instead of swinging in the turning basin, the vessel drifted toward the north shore, where she came to rest for the second time. This time, unlike the first grounding, the vessel was not crosswise to the current. Therefore, two tugs had to be secured to the vessel's stern to pull her clear of the bank. Over the course of their careers, pilots gain extensive experience in ship handling, but they very seldom have to deal with a grounding. Like pilotage, marine salvage is a field where experience is acquired over time. It is possible that the second grounding happened because the shipowners' representatives, the navigation personnel and the pilots involved in the refloating lacked experience in marine salvage techniques. 2.6 Duration of the Pilotage Assignment and Pilot Performance When the first grounding occurred, the pilot had had the conduct of the vessel continuously for over seven hours. He was on duty for approximately 24 hours in all. Refloating a vessel is a very demanding manoeuvre that requires high levels of concentration, good judgement, alertness, and immediate response to a developing situation. As the pilot of the VENUS was not assisted by another pilot, he was probably fatigued, and his fatigue most probably contributed to the degradation of his ability to perform monitoring and decision-making tasks. Since no medical assessment of the pilot was performed following the two groundings, the extent to which his performance may have been degraded by sleep debt could not be established. As fatigued people are poor judges of their own fatigue and alertness levels, it is unlikely that the pilot's self-assessment was objective when he decided to retain the conduct of the vessel; in doing so, he delayed calling for a replacement. Pilots should not assess their level of fatigue on their own. There are no provisions in the regulations nor in the service contract that provide for another pilot to be dispatched immediately; this suggests that those concerned do not fully appreciate the adverse effects of sleep debt on performance. When a pilotage assignment is extended due to a marine accident or incident, there is no program under which the pilot can request to be assisted or relieved, and the safety of the vessel may be jeopardized. 3.0 Conclusions 3.1 Findings The navigation personnel relied on the pilot, on his knowledge of the area and on his ability to conduct the vessel. The navigation personnel were using a marine chart that did not show the unidirectional range light. The navigation personnel did not take part in planning the approach manoeuvre in the turning basin. The pilot and the navigation personnel did not discuss the manoeuvre to be performed in the turning basin. The navigation personnel did not monitor closely the progress of the VENUS. Neither the pilot nor the navigation personnel used radar to navigate by parallel indexing. There was no buoy or landmark in place to mark the downstream limit of the turning basin and to facilitate lateral observation. The pilot used landmarks that required him to execute the approach manoeuvre near the shoal along the downstream limit of the turning basin. The navigation personnel did not increase main engine speed to slow ahead and the pilot did not look to see if his orders had been carried out. The current off the harbour entrance set the vessel toward the shoal at the downstream limit of the turning basin. The spring run-off was conducive to silting in the harbour approaches. The vessel struck an obstruction that probably consisted of unreported silt deposits in the turning basin or along the shoal at the downstream limit of the turning basin. The orders to further increase speed were given too late. The vessel was swung round by the current and grounded. The effect of the current on the vessel's hull was underestimated on the first refloating manoeuvre. It is possible that the second grounding is attributable to a lack of marine salvage experience on the part of the shipowners' representatives, the navigation personnel and the pilots involved in the refloating manoeuvre. The pilot was on duty for approximately 24 hours. Pilots should not assess their level of fatigue on their own. There are no provisions in the regulations nor in the service contract for the immediate assignment of another pilot to assist or relieve a pilot involved in a marine occurrence. When a pilotage assignment is extended due to a marine occurrence, the pilot's performance may be degraded and the safety of the vessel may be jeopardized. 3.2 Causes The VENUS grounded because an order to increase speed was not transmitted to the engine-room by the navigation personnel, and the pilot did not confirm that it was. The vessel's speed was insufficient to allow her to stem the current, and she was set toward the downstream limit of the turning basin, where she struck an obstruction. Following bottom contact, the vessel suddenly swung to port. The heavy spring current set the vessel toward the edge of the basin and the vessel grounded. The heavy concentration of shoals surveyed would seem to indicate that the obstruction was formed by silting. 4.0 Safety Action 4.1 Action Being Taken The Great Lakes Pilotage Authority Limited has developed a training package on bridge resource management (BRM) and fatigue awareness and delivered it to all of its pilots. The General Pilotage Regulations are currently being amended to make BRM training a mandatory requirement.